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Published on 1 January 2006

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Issues in computerised prescriber order entry

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Toby Clark
RPh MSc FASHP
Clinical Associate/Professor of Pharmacy Practice
College of Pharmacy
Medical University of South Carolina
Charleston, SC
USA
E:tobyclark@att.net

Since the publication, in 1999, of To Err is Human, the Institute of Medicine’s landmark report, more attention has been given to the important topic of patient safety. The IOM reported that as many as 98,000 individuals die each year in US hospitals from preventable mistakes on the part of physicians, nurses, pharmacists and other caregivers.(1) To meet this challenge, many hospitals have made the commitment to implement computerised prescriber order entry (CPOE), a process where primarily physicians (including some nurses and pharmacists) write medical orders for patients using clinical software in computer systems.

Implementing CPOE brings a host of changes on a large scale to the hospital because it may be the first time the facility has applied widespread technology to clinical processes including physician, nurse, pharmacist and other caregiver workflows. Information technology reduces rates of errors in three different ways: by preventing errors and adverse drug events (ADEs); by facilitating a more rapid response postADE; and by tracking ADEs.(2) CPOE directly affects the safety, quality and productivity of the medication system. At the same time, CPOE will eliminate or reduce some types of errors and introduce the potential for new types of prescribing errors!(3,4)

CPOE planning
CPOE installation and operation need to be developed in stages consisting of planning, selection, design, construction, testing, training, implementation and operation (with quality safety review).(5) Each of the stages needs a written plan that elaborates what is to be done and who is accountable for success. One of the most important and often minimised functions is that of planning. A common pitfall is the lack of a medication system technology strategy (MSTS) or vision that is understood by all the administrative and caregivers collaborating together for the successful installation of the CPOE system. Table 1 shows a sample MSTS and medication flow within the envisioned technology-enriched medication system.(5)

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Hospital readiness for CPOE
An important aspect when considering the purchase and installation of an electronic health record system with CPOE is the culture and readiness of the hospital to undertake such a gigantic programme. There are many reasons for this. First, the changeover from handwritten to computer- genered orders significantly alters the order process and workflow for clinicians, and many changes must occur in the interdepartmental handoffs of the medication system. In addition, many hospitals lack experience in clinical systems and an information technology structure is needed. This is coupled with the need for standardisation of clinical practice at all levels, because the computer system will guide the process. Hospitals considering the installation of an electronic health record system increase the likelihood of operational success by understanding, measuring and addressing gaps in CPOE readiness.(6)

Kent and Boecler described the implementation of a totally integrated pharmacy system, electronic medical (health) record (EHR) with CPOE and electronic medication administration record in three closely affiliated hospitals and 50 physician offices.(7) The pharmacy/medication system portion of the EHR included about 16 months of software development, performing detailed workflow analysis, building medication master files and training 185 pharmacy employees. “Super users” were established to provide training, go-live support and direction for future system improvements.

Additional lessons learned from other pharmacists with CPOE implementation experience provides much insight for those venturing down the CPOE pathway.(8)

Pharmacy’s role in the CPOE process
Because of the complexity of the medication system, pharmacists need to take a proactive leadership role in the CPOE process. Pharmacy must be involved in several key decisions early in the process:

  • Is the CPOE system a standalone system or is it a comprehensive system that includes medications charting, results reporting and the entire patient’s chart?
  • Will clinical decision support be a feature?
  • Will the CPOE system interface with the current pharmacy system or is a replacement pharmacy system necessary?

Because CPOE will change so much in pharmacy departments, the pharmacy leader must devote time to CPOE planning:

  • Create a flowchart of current medication system processes for all the steps in the system with the aid of an interdisciplinary team who know all the steps. Be sure to include order verification before the dispensing process, because we, as pharmacists, do it and that is what differentiates us from all other caregivers.
  • Involve the Pharmacy and Therapeutics Committee (or a similar committee of medical staff with nursing collaboration) and appoint a reporting committee to focus on CPOE.
  • Make sure the project goals are defined very clearly. When possible, gather before data on the safety, quality and productivity of the medication system. Formulate a plan for collecting the same data after installation has been smoothed so that goals can be measured objectively.
  • Carefully plan for additional pharmacist resources for all phases of the project. CPOE will require more fulltime-equivalent pharmacists positions for all of the pre-installation functions as well as for the post-“go live” operations. Some estimates are that three to six additional pharmacists are required for system table maintenance and clinical decision support effectiveness.

Proper installation and operations of your CPOE system will change the role of the pharmacist in your institution depending on how you build the system.  But remember that each system is different, as each hospital pharmacy is different. Planning is the key to success.

References

  1. Kohn LT, et al. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
  2. Bates DW, Gawande AA. Improving patient safety with information technology. N Engl J Med 2003;348:2526-34.
  3. Gouveia WA, et al. Computerized prescriber order entry; power, not panacea. Am J Health-Syst Pharm 2003;60:1838.
  4. Clark T. Computerized physician order entry prescribing events impeded by pharmacists. ASHP Midyear Clinical Meeting 2000;35:TTIP-3 (Abstract).
  5. Clark T. CPOE-medication system strategy. ASHP Summer Meeting; 2002;59:PI-14.
  6. Stablein D, et al. Understanding hospital readiness for ­computerized physician order entry. Jt Comm J Qual Saf 2003;29:336-44.
  7. Kent SS, Boecler LA. Implementation of a pharmacy computer system integrated with computerized physician order entry an electronic medical record. ASHP Midyear Clinical Meeting, 2004;39;MCS-23.
  8. American Society of Health-System Pharmacists. Computerized Prescriber Order Entry Systems. Available from: http://www.ashp.org/patient-safety/Landmines.cfm?cfid=4598771&CFToken=21824673


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